After losing 500 pounds, removal of excess skin problematic

By SHARI RUDAVSKY -

2/8/18 5:02 AM

INDIANAPOLIS — Bariatric surgery held out the promise of a new life for Stanley Hollar, who at his peak weight tipped the scales at nearly 700. Two years after his surgery, the Rushville man has lost nearly 500 pounds. But his days of obesity still haunt and hobble him – literally.

Hollar, who lost his leg below the knee years ago, can no longer use the prosthetic that fit his former, much larger self. He also carries around pounds of excess skin that further impede his motion. For while his fat has melted away over the past two years, it left behind the skin that once encased it.

“I have bat wings on each arm that drop down about four inches… I can pull back my love handles and pull the skin up four or five inches,” said Hollar, 42, who currently carries about 190 pounds on his 5’10” frame. “I have excess skin hanging from just about everywhere…. My skin looks like a pair of MC Hammer pants. I need to make it more like nylons.”

However, most insurance carriers, including Medicare which Hollar has, decline post-bariatric skin removal surgery, deeming it cosmetic. So Hollar is trying to raise $25,000 to cover the costs of surgery and a new prosthetic that will fit his new leg. His old one is the circumference of his new waist.

Many patients who undergo bariatric surgery find themselves struggling in the aftermath to finesse additional treatments, such as the skin removal surgery Hollar desires, experts say.

And most patients over the age of 30 who have bariatric surgery can expect some loose skin, Dr. Samer Mattar, president of the American Society for Metabolic and Bariatric Surgery. Past that age, skin tends to lose its elasticity, so if someone loses a substantial amount of weight, the skin will not just recoil. The resulting skin can lead to health problems such as rashes or infections.

More than half of the patients who undergo bariatric surgery could benefit from skin reduction surgery, said Dr. Scott Kahan, a spokesperson for the Obesity Society. About a third could have health reasons for having such a procedure.

As a bariatric surgeon, Mattar said he sees little difference between this surgery and breast reconstruction for women who undergo mastectomies.

“Why would you exclude them from having this very beneficial coverage?” said Mattar, also director of Swedish Weight Loss Services in Seattle. “It’s a form of discrimination and bias against poor people who have suffered all their life. They are finally making very courageous, momentous decisions and this is part of the continuum of care.”

More than half of the patients who undergo bariatric surgery could benefit from skin reduction surgery, said Dr. Scott Kahan, a spokesperson for the Obesity Society. About a third could have health reasons for having such a procedure.

As a bariatric surgeon, Mattar said he sees little difference between this surgery and breast reconstruction for women who undergo mastectomies.

“Why would you exclude them from having this very beneficial coverage?” said Mattar, also director of Swedish Weight Loss Services in Seattle. “It’s a form of discrimination and bias against poor people who have suffered all their life. They are finally making very courageous, momentous decisions and this is part of the continuum of care.”

Often Mattar will try to help his patients by documenting the health toll the excess skin takes, listing the various complications that it has caused. Sometimes he’ll take pictures of the patient and send that along to the insurer. He’ll refer his patients to a dermatologist, suggesting that instead of treating the skin irritation with an over-the-counter cream, they incur the cost of a doctor’s visit and a prescription medicine, more proof that the problem is not a solely cosmetic one.

Kahan, who does not perform bariatric surgery, also will frequently go the extra mile for patients, circling back to the insurer after coverage for a procedure is initially denied.

“It takes a lot of work but a lot of times we do see that we can get coverage in the long run but it’s a convoluted path to get there,” said Kahn, director of the National Center for Weight and Wellness.

In some cases, insurers do cover treating an underlying medical condition that arises from excess skin, said Cathryn Donaldson, communications director for AHIP, America’s Health Insurance Plans, a trade association for health insurers. If an insurer turns down the first request for coverage, saying it’s not medically necessary, a patient can always appeal.

“Health insurance providers work to ensure patients have access to effective, quality, evidence-based care they need,” Donaldson said in an email. “Overall, specific coverage and benefits for any procedure, including post-bariatric surgery, will vary based on the individual, the health plan they select, network, and local market.”

Many patients cannot even swing bariatric surgery financially, even if their insurer technically covers it, Kahan said. High co-pays and deductibles can put the potentially life-saving operation out of reach. One patient he saw recently had coverage but the out-of-pocket cost to him would exceed $10,000.

The only route that Mattar sees to change lies through legislation. Without that, he said, insurers will have no incentive to amend their policies.

Stanley Hollar can’t wait for that. Currently he moves around by “scooting” from place to place. He kneels on his wheelchair with his amputated leg and pushes off the ground with his good leg. He walks a few laps a day around his small town of Homer and this fall he completed a 5K. It took him an hour and 10 minutes.

But there was a time that Hollar could never even imagine completing a race. All his life, he’s been overweight. In kindergarten, he weighed almost 100 pounds.

“I was on the tall side but nice and round too,” he recalled.

Everyone in his family carried some extra pounds, so Hollar didn’t worry much about his size. By the time he reached Kentucky Christian University in the mid-Nineties, though, his weight surpassed 400 pounds. In 1996, during his second year of college, at the age of 20, he injured his right knee playing intramural indoor soccer.

Doctors examined him, put him in a cast from mid-thigh down to his toes to immobilize his leg, and recommended physical therapy. But in part because Hollar was too large to undergo an MRI, the doctors did not realize that he had torn an artery in the back of his right knee.

Two weeks later, Hollar’s leg was amputated from the knee down.

The amputation did not persuade Hollar it was time to change his eating habits. Over the next two decades, his weight went up and down but never got much below 350.

At the start of 2015, Hollar’s weight pinnacled at 678. He started to feel sick, unable to move around much, or take substitute teacher assignments as he had when he was healthier. One day, he could not move at all and his mother called an ambulance.

The extra pounds had taken a toll, causing fluid to build up throughout Hollar’s body, he said. His lungs had filled with fluid, making it difficult for him to breathe. Doctors inserted a trach in his throat to help him breathe and prescribed heavy diuretics to help him shed the excess fluid.

After 10 days in the hospital, Hollar transferred to a long-term care facility in Greenfield.

By that time, he had resolved to take the weight off for good.

“When the doctor basically says, you need to start losing weight or you’re not going to make it until your next birthday and I’m only 39, it kind of says, ‘Hello!'” he said.

Within a month, he lost 120 pounds, most of it fluid. In mid-March, he transferred to another facility in Lawrenceburg. He still weighed more than 500 pounds and had to be on oxygen.

In all, Hollar spent 159 days in health care facilities.

When he finally came home in July of 2015, he resolved to keep losing and build up his strength to undergo bariatric surgery, a procedure that his mother and two brothers had gone through with beneficial results. He started with 10 to 15 minute at a time on a therapy bike, pedaling away while listening to the country music he loves.

The following March, Hollar had gastric bypass surgery. At the time of his surgery, he weighed 429 pounds. He also still relied on oxygen to breathe, carrying an oxygen tank wherever he went.

He did not allow that to deter him from exercise. He started with short walks down the driveway, then further down the road, one mile then two. A few months later, he joined Anytime Fitness in Rushville and started working out five days a week, often walking on weekends.

By September, when he finally had his trach removed, he was down to 313 pounds.

“The last time I was down around 300, was somewhere around junior high,” he said.

By the following June, he cracked the 200-pound mark, a weight he had not seen since fourth or fifth grade. The only problem? The excess skin reminding him of his past and impeding his future.

After consulting with Dr. Christopher Jones, an Indianapolis plastic surgeon who has expertise in body contouring for post-bariatric surgeons, Hollar resigned himself to the notion that he’d never be able to have skin-removal surgery.

While Jones offered some assistance with the cost of surgery, he told Hollar the associated costs of the procedure, such as anesthesia and operating room fees, would still come to about $25,000. Wrestling with insurance companies led Jones to decide not to even head down the path of trying to seek reimbursement for surgeries.

“Frankly the reason why I’m not a covered entity, is it became so onerous to try to convince any insurance company that some of these concerns of patients are truly medically necessary,” Jones said. “They (the insurers) took medically necessary out of my hands and put it in their hands.”

Things might have rested there if not for one of school classmates. Michael Hurst had helped another friend with ALS raise $46,000. After meeting Hollar at the gym, Hurst’s brother-in-law urged him to try to do a similar thing for Hollar.

Over the years, Hurst had run into Hollar a few times at basketball games; Hollar, who has worked as a substitute high school teacher, tries to attend every Rushville High School basketball and football game he can. And of course, he stood out.

“He was known for his size. He’s been the biggest guy that I have known pretty much my whole life,” said Hurst, who lives in Greenfield.

At first, Hurst said, he did not understand why it would be such a major issue for Hollar to have a new prosthetic fitted. Then Hollar showed him the extra skin he was dealing with.

“I couldn’t believe that insurance wouldn’t cover it. It seems like it’s medically necessary,” Hurst said. “He’s learned to manage quite well…but it limits him on certain things from living a normal life.”

The Help Stanley Walk campaign has already raised enough to cover the first surgery and half of the second, Hollar said recently. He hopes to have the first procedure in June and within two years have mastered how to walk with his new leg.

For now, Hollar is focused mainly on walking on his own again. After that, anything is possible.

“I haven’t looked past what’s going to happen afterward,” he said. “You never know what life will bring after all these changes happen. My life has changed a whole bunch in the last two and a half years and it will change a whole bunch more.”

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